0205-105 (RR)I V11 L,#L_%,LmnAi iUN
i4eby.'affirm -under, Obnalty:of,pedury. that.,I aim licefiged,.,uncler. pr6;Isions;of vt
T . 1 4 . - ael�
iaptbr 9.(conn"mc�icinq with Sed6n',1660'6f D'MSJdr13 of the',Business and.
,bfessi6nils Code, and 7my,Llcensi IiI1rifull force, and effect. -
k6rise # Uc.,Class Exp.'Date
1 1457;
-�C-350 D/03
j6
�Vte,----Ql�-dfiihaofContra
Ci_
V
4tiper !, 'Y'Xw- !.�.,�,.��,'OWNER-BLIILDEIIF!11DE ;q(A ri N
iqrei by�lqWirm, ul'h_�di�r penalty of perjury,,that I am exempt from the Contractoe.s
;ense`.�Lawfortheifollowing reason:; -,
,),ll,,i§oWh6r.z6fthe ,'property, -ormy,'eriioloyees with wages as their sold*
impensation;6w'l4,'d61thd work, and the structure is not Intended or offered for
le;(Se6:,104i�dU s(ness & . Professionals, Code).,.:.
J
,I.- exclusively contracting with licensed
intractors-to -consfructihe'L project ,(Sec 7044 Business & 'Professionals
er4 Section reason
L . Ai'
'.,I 6m."eierhot"und ��-�B&RC��fo'r this
_7
"firSlgnatui�,e of 6wrier-1
WORKER'S' COMPENSATION DECLARATION
iereby.affirrh;;undee.-'06imnalty of perjury one of! the: foll6wing declarations:
aln, I ainj'66rtifjCjj6.of consent to self -'insure for workers'
mpensation'- ig- j�i6v1'd;d i6i,by,: Section, 3700:. oft the Labor Code, for:the
j.
'rfdr;m dn'c6!'ofthe':work'for Which this permit is IsSu'
ad
VhaveLLind-Wil,amairiii6' i 'workers' compensation,* insurance, as required by
ori'3700'ofFthe Labor; de';,Jor the' jj'rf&e,
eman�of the work for which this
rmft'ils lssue&IV1y'.woiHkers' compensation insurance carrier & policy no. are:.
4
k-
0 Policy No
his section 'L need not be completed if the'06rin(t valuation is is"for'$100.00 or less).
',I CbrtifythatL In,the p4rf6imarice �OfiKile - work f&which this permit is Issued,:
ihall 'no_f_em`plo`y�,any , .pe . rso I min -any, manner . er so as .. to become subject to the
ers`compensation...Llaws""r" i: alifo' I'd','.. and agree that if lJhould.be6ome
Ci" 'the
compensation 1,
0ji '6wor.ers, prov siorts of Section 3700' ,of `eL Labor,
ode it ` forthwith " : itthose_
I: fo'r'thw- h comply w
al :
A nAile�a:hf
4V�
61'e"ct"a*n"'e'm:'p-l'o"yer,'t6,6���ifii-17p�6ilile'iand�*61�-11 flnes-u ''to $100.000. (n.,
, . * , compensation '_,1�1, '. - . , provided , . , I P
to;the cost of.' ,, damages. as provided for in Section 3706. -
attorney's fees
rANT00 d n- ty
plication, s�herbby made; the Bullg andSafe
. I '
set forth on his .
-h-06t6on upon,Whose bihalf this lippli6itio ls made
i & eachpersonat
9- request and fnrWhoiti'be'neilt worlds performed under or pursuant to
erilt'ls,SuAd,a's &.Iesult of. -this 60plicaton agrees to & shall, Indemnify
d Arimliegs the City bf)Li'Q Ulhiai.its offlders,'age'nts and employees.
V'Permlt issued:ae'a result,of.thls applicationbecomes null and vold.if
)s' not , b6mr4iced '6thln�'11601.daiye from- 'd I ate of -Iss , uance of such
tj.,.or deiiitloh, 6f,Work'-for 180 aIiys"will subje6t perrinit to cancellation.
ihat'I',_have,read_this ipplication',and state,tKat the above Information Is
I, I V agree .., toI . .,'comp.ly,,with i allClty,,and ' City,'and State laws relating to the building
:
.tion, and ' hereby duthorlie, representative's of this City to enter upon
vd-.m6ritlorfid property for Inspecbon �?sqs.
rel"(OwneriA6ent) Dates
PERMIT#
Y�_,X'KRAA BU MING R E R M IT W
wo
OAT L OT 'TRACT
�7
JOBSITE*,�'-
ADDRESS -4 1- MDOW1,11
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
WM REMMIAL HOMOW10W
PCNATIMM-0-MM-D
OF CAT. 0
R0. BOX 1060
67-555 EA91' PAW CANYON-JAIn
1A Qlj-M'rA
OW1:11R)RAL CDT' CA
(1w)J25.9111 CBI* 4611
USE OF PERMIT
RE-WOPWITH CLA' .54-A MATERIM.& 11100. IS: 54-331, 54.321.
54.11.% 44 301 -OAK
VALUATIOW ;4946.00w
MME[TYKE WAMARY
1111'0�P' ' -101-000.418-0%)
4,
MAY U
WYORAQUINU
FRI CEDED'
fftYfA,-Kff.AL C0NISIMUM ON'AND PLAN CHW 9(
$30.00
LJ4;93 PIM PM) k,JWi
X0,00
TOTAG rERM FEES DUE NOW
04 0�
r RECEIPT
DATE
1211,
A,1
oil
PE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROV S
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
_
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS: /
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
t
r